Herpes Simplex Virus-2 Hepatitis: A Case Report and Review of the Literature

Abstract

Herpes simplex virus (HSV) is a rare cause of hepatitis in pregnancy and the chronically immunosuppressed, with a high propensity to progress to acute liver failure (ALF) and death. Patients typically present with a nonspecific clinical picture that often delays diagnosis and treatment, contributing to the high mortality rate. We present a case of a young female on chronic prednisone and hydroxychloroquine for systemic lupus erythematosus (SLE) who was diagnosed with HSV-2 hepatitis after presenting with right-sided chest and abdominal discomfort. Despite early clinical deterioration, prompt initiation of therapy with intravenous acyclovir and methylprednisolone led to rapid improvement.

Figure 1

Trends of liver function tests (AST, ALT, and total bilirubin) and liver synthetic function (platelets and INR) over the course of this patient's hospitalization and follow-up visit. A. Initiation of intravenous acyclovir. B. Initiation of oral valacyclovir. C. One-month follow-up visit showing normalization of liver enzymes, platelets, and INR. AST: aspartate transaminase; ALT: alanine transaminase.

Figure 2

Transjugular core needle biopsies of the liver showed patchy involvement by well-demarcated areas of necrosis with associated inflammatory cells ((a) H&E stained slide, 100x magnification). The intervening liver parenchyma was unremarkable. A higher power view shows that the hepatocytes at the periphery of the areas of necrosis have glassy nuclear chromatin with margination and occasional multinucleation ((b) H&E stained slide, 400x magnification). Immunoperoxidase stains for herpes simplex virus (HSV-1/2) were performed and showed positive nuclear and cytoplasmic staining, characteristic of HSV-related hepatitis ((c) and (d) 100x and 400x magnification).